Get Pp-600-us-1281 2015-2025

This guide provides clear and detailed instructions for completing the PP-600-US-1281, the insurance benefit verification request form used by referring providers for Xofigo® services. By following these steps, users can easily navigate the form and ensure all necessary information is accurately submitted.

Follow the steps to complete the PP-600-US-1281 online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by filling out the Referring Provider Information section. Include details such as referring provider name, specialty, NPI number, tax ID number, practice name, and practice address. Ensure accuracy in the city, state, and zip code provided.
3. In the Patient Information section, enter the patient's name, date of birth, address, email, phone, and the scheduled treatment date and time. Confirm the option to allow contact.
4. Complete the Patient Insurance Information section. This requires entering the primary and secondary insurance details including policy numbers and contact information for the insurance providers.
5. Review and fill out the Physician Declaration section accurately. The healthcare provider must sign and date this section to affirm the accuracy of the information provided and consent to the service terms.
6. Proceed to the Patient Authorization for Xofigo Access Services. The patient or their representative must sign and date, confirming their understanding of the authorization regarding personal health information.
7. Once all sections are complete, review the form for accuracy before finalizing. Users can then save changes, download, print, or share the form as needed.

Complete your insurance benefit verification request form online today.